This was a operational safety protocol formulated for uninterrupted functioning of radiotherapy and oncology department during covid

1. COVID-19 operational protocol for
advanced radiotherapy centre: a
single institute experience in
central India
Dr. Gopa Ghosh (Professor)
DEPARTMENT OF RADIATION ONCOLOGY
CMCH ,Bhopal.

2. Lock-Unlock sequences
• DateNationwide lockdown:Phase 1: 25 March 2020 – 14 April 2020 (21 days)
• Phase 2: 15 April 2020 – 3 May 2020 (19 days)
• Phase 3: 4 May 2020 – 17 May 2020 (14 days)
• Phase 4: 18 May 2020 – 31 May 2020 (14 days)
• Unlock:
• Unlock 1.0: 1 June 2020 – 30 June 2020 (30 days)
• Unlock 2.0: 1 July 2020 – 31 July 2020 (31 days)
• Unlock 3.0: 1 August 2020 – 31 August 2020 (31 days)
• Unlock 4.0: 1 September 2020 - 30 September 2020 (30 days)
• Unlock 5.0: 1 October 2020 - 31 October 2020 (31 days)
• Unlock 6.0: 1 November 2020 - 30 November 2020 (30 days)
• Unlock 7.0: 1 December 2020 - 31 December 2020 (31 days)
• Unlock 8.0: 1 January 2021 - 31 January 2021 (31 days)
• Unlock 9.0: 1 February 2021 - 28 February 2021 (28 days)
• Unlock 10.0: 1 March 2021 - 31 March 2021 (31 days)
• Unlock 11.0: 1 April 2021 - 30 April 2021 (30 days)
• Unlock 12.0: 1 May 2021 - 31 May 2021 (31 days)
• Unlock 13.0: 1 June 2021 - 30 June 2021 (30 days)
• Unlock 14.0: 1 July 2021 - 31 July 2021 (31 days)
• Unlock 15.0: 1 August 2021 - 31 August 2021 (31 days)
• Unlock 16.0 : 1 September 2021 - 30 September 2021 (30 days)
• Unlock 17.0 : 1 October 2021 - 31 October 2021 (31 days)
• Unlock 18.0: 1 November 2021-30 November 2021 (30 days)
• Unlock 19.0: 1 December 2021-31 December 2021 (31 days)
• Unlock 20.0: 1 January 2022-31 January 2022 (31 days)
• Unlock 21.0: 1 February 2022-28 February 2022 (28 days)
• Unlock 22.0: 1 March 2022-31 March 2022 (31 days)
Source:
https://www.mohfw.
gov.in/

3. New normal to normal
• life is back to normal
• VIRTUAL  IN PERSON
• SOCIAL DISTANCING SOCIAL INTERACTION
• LESSON LEARNED Big emergencies require
swift,effective and concrete emergency response plan.
• Emergency preparedeness can reduce
fear,anxiety,losses that accompany disasters.(Blog
byTanya Borthick,Canadian centre for occupational
health and safety).
• Significance or essentiality of safe practices can never
be undermined.

5. Introduction
• On January 30th in year 2020, the World Health Organization (WHO) has declared
the coronavirus outbreak (COVID-19) a global Public health emergency.
• To contain the spread of COVID-19, government has closed public places, public
transport and also imposed laws to prevent social gatherings. Till September 2020
in India alone total no of cases were around 41 lakhs while active cases were
around 8 lakhs whereas approximately seventy thousand people died of infection
till this article was written [1].
• During this period of pandemic health care workers and medical professionals
were at highest risk of exposure and to prevent transmission among them many
institutions have implicated their own guidelines.
• According to the WHO main measure to curb COVID-19 pandemic is quarantine
and social distancing making difficult for patients to visit hospitals [2]. As patients
diagnosed with malignancies are already immunocompromised and requires a
long-term treatment they are under highest risk of getting infected during
treatment and follow-up.
• In present study we are analyzing the data of radiotherapy department of a cancer
institute where a generalized guideline for safety during pandemic was followed to
ensure the safety of patients, hospital staff and health care workers working in the
institution.

6. Patient and Method
• During the period of pandemic guidelines were made for the proper and regular
functioning of the department as soon as COVID-19 was declared as pandemic
• Guidelines to be followed during this pandemic
• Primary Desk of Cancer Hospital/Reception
• • Protect working people in reception areas. [PPE]
• .
• • Educate them with importance & ways for infection control, Prevention &
enquiry techniques.
• • All patients should be ENQUIRED about the following:
• - International travel within the last 14 days to countries with sustained
community transmission.
• - Signs or symptoms of a respiratory infection, such as a fever, cough, and sore
throat.
• - In the last 14 days, has had contact with someone with or under investigation for
COVID19, or are ill with respiratory illness [3].

7. Patient and Method
• Visitors’ Guidelines
• • Restrict visits of non-essential visitors except for certain situations, such as an end-of-life
situation.[5]
• Visitors will be screened prior to entering patient areas. If symptomatic asked to visit fever clinic as
soon as possible.
• • The number of visitors per patient will be limited to one or two; additional restrictions may be
imposed based on the patient’s clinical status.
• • No visitors should be allowed in IPD sections if the suspect or COVID-19 patient is identified.
• • Relatives of other patients should preferably avoid frequent or mass visits unless warranted.
• • Visits by Children should be avoided & should be supervised at all times by an adult if they visit
hospitals/wards.
• • Visitors should also preferably provide photo identification for Record with the cancer block
securtiy personnels .
• • Visitors should practice good hand hygiene.
• • Already ill or sick persons should avoid visits to hospitals to avoid cross infections.

8. Patient and Method
• Screening of patients (OPD guidelines)
• At primary visit of patient vitals monitoring of
patient was done (including blood pressure,
pulse, oxygen saturation, temperature e.t.c).
• Prior to simulation of patient all routine
investigations including blood (CBC, RFT, LFT, CRP,
ESR), Chest X-ray PA view were advised.
• RT-PCR was advised to patients who were
symptomatic or having any contact history or any
history of travelling to infection prone areas.

9. Patient and Method
• In-Patient Department (IPD) & Hospital Staff Guidelines
• • Hospital staff should regularly be given information about the epidemic.
• Prompt detection, isolation of potentially infectious patient is essential to
prevent unnecessary exposures to other patients or visitors & healthcare
personnel.
• • Therefore, Hospital Staff should continue to be vigilant in identifying any
possible infected individuals.
• RT-PCR of admitted patients was mandatory
• Distancing between hospital beds should be adequate. If not, kindly
adhere to the norms with immediate effect.
• • Hand hygiene & Personal Protective measures should be followed in
admitted patients & serving staff.
• • Assign a staff as primary contact to attend relatives over phone with
recording facility.

10. Patient and Method
• Equipment Management guidelines
• Treatment and physics equipment- Clean or sterilize before
and after use and in between patients.
• Equipment in patient contact e.g. Motion management,
brachytherapy- Re-evaluate which equipment is essential
for treatment/QA to proceed.
• Radiation safety equipment- Ensure radiation monitors and
all interlocks are fully functional. Be aware of infection
transmission risk at personal monitor and other monitoring
devices changeover.
• Cleaning agents- Determine which ones are suitable for
each type of equipment. Include cleaning of IT equipment
and mobile phones too[6]

11. Patient and Method
• Quality Assurance
• Prioritization- Decide what is fundamental to safety, legally required and essential
for ongoing treatment, prioritise the remainder according to resource constraints.
• Scheduling- If not already done so, move QA and nonessential work to weekends
and out of hours, or cancel. , only the monthly QA can't be differed.
• Reduced workforce- Consider how much QA can be done by the existing
workforce.
• Safety
• Radiation Safety- With changes to workflow and staff rosters, consider if this
impacts on the safety of patients, staff and visitors.
• Functionality of equipment- Preventative or routine maintenance and QA schedule
to ensure equipment works for its intended purpose smoothly.
• These guidelines were made to be followed during this period of pandemic. At
completion of 6 months an assessment was done to observe the impact of these
guidelines on working of radiation oncology department and risk of transmission
of infection among patients and health care workers associated with radiation
oncology department.

12. Results
• As soon as Government of India has declared complete
lockdown in whole country to ensure the protection of
public from COVID-19 infection our institution has
developed strategies in first week of april 2020 itself
regarding the proper functioning of cancer hospital where
our first step was to develop a strong guideline which can
be implicated easily and should be effective enough to
control the transmission of infection in department and
institution. Secondly, we have to involve every person
working in the institution and we have to encourage each
and every worker of institution to strictly adhere to the
guidelines made by hospital.

13. Results
• Departmental guidelines were made for radiotherapy of the patients and evidence based
hypofractionated EBRT planning was done wherever possible (H&N ,Breast, lung,shorter palliative)
for eligible patients(Table-2).After six months of following the guidelines a departmental evaluation
was done in order to observe the impact of implicating the guidelines for control of transmission of
COVID-19 infection.
• From April 2020 to September 2020 a total of 113 new patients received external beam
radiotherapy (EBRT) (Table-1) and 30 patients received brachytherapy. Among these patients two
patients of EBRT were diagnosed with COVID-19 infection after simulation and during treatment
while none of the patient of brachytherapy was diagnosed with COVID-19 infection during
treatment. All contacts of patients diagnosed with infection were referred to covid facility were
quarantined or treated as per standard guidelines .Affected areas of Department were sealed and
proper sanitisation was done for 72 hours and during this period RT-PCR of every patient
undergoing EBRT was repeated. After 72 hours EBRT of patients who were reported negative in RT-
PCR was restarted.
• With all these preventive measures we were able to control rate of transmission of infection in our
department as much as possible. The diagnosis of patients during treatment was possible because
of close and routine vital monitoring of the patients with evaluation whenever required.

14. Results
• For every patient undergoing simulation CT scan of thorax was made compulsory irrespective of the
treatment site so that evaluation of lung can be done prior to start of treatment without giving any
extra financial burden to patient.
• In those patients where CT thorax was suspicious for coronavirus infection RT-PCR correlation was
made and patient was started on EBRT only if his/her RT-PCR report is negative and such patients
were also kept on close monitoring of symptoms related to COVID-19 infection.
• CT thorax was helpful in screening of asymptomatic and RT-PCR negative patients so that those
patients can be isolated.
• During this period of six months two patients were diagnosed of COVID-19 infection after
simulation and prior to start of radiotherapy treatment. These patients were then admitted in
COVID-19 facility of the hospital where they received required treatment and were discharged with
negative RT-PCR reports. After discharge these patients were again assessed and then planned for
radiotherapy.
• Among the patients who have been taken on radiotherapy treatment after negative RT-PCR report
those who were having significant CT findings in thorax RT-PCR was repeated after one-week period
and till that period of one week those patients were treated every day at the end of the day only
after completion of treatment of rest of the patients so that after treatment the treatment couch
can be cleaned and sanitised. On first week follow-up of these patients four patients turned out to
be RT-PCR positive.
• As on 6 month evaluation our protocol was substantially effective in continiuing uninterrupted
patient treatment , so it was continued with some modiication till the cases started declining and
first dose vaccination of department staff was initiated.

15. Table 1
Table1: Total patients treated in between April to September 2020 at
radiotherapy department of a cancer institute in central India.
Total no. of new
patients
No. of RT-PCR
positive patients
No. of patients
suspicious on CT
thorax
No. of patients
positive among
suspected patients
Total patients
completing
treatment
(Compliance)
113 04 17 02 103

16. Table 2
Table2: Patients receiving hypofractionation and conventional
fractionation.
Diagnosis Total no. of
patients
No. of patients
treated with
hypofractionation
No. of patients
treated with
conventional
fractionation
No. of patients
completing
treatment
Head and neck
cancer
82 67 15 76
Cancer cervix 12 00 12 12
Breast cancer 10 00 10 10
Others 09 05 04 5

17. Discussion
• Like the most countries, India was also found unprepared to continuing
routine healthcare during COVID-19 pandemic. It had considerable impact
on cancer treatment delivery in India.
• The long-term impact is likely to be increased on cancer stage migration
and outcomes due to interruption of cancer screening program and
delayed hospital visits during the COVID-19 period[7].
• In our protocol we had taken some the measures to reduce the effect of
pandemic on cancer outcome which are similar to the study of Wei Wei et
al [8] and Pramesh et al [9]. Our anti-COVID protocol for radiotherapy
department has been effective to stop spreading of COVID-19 infection
throughout among patients to a very limited level. Due to the personal
protection measures and awareness program included in our protocol the
risk of spreading infection among our health care professionals has been
substantially reduced, hence ensuring treatments to our patients with
high compliance rate of 91% . Mandatory RT-PCR of every patient before
RT,CT –Lung screening of every patient, close monitoring of symptoms and
repeat RT-PCR were key elements of our protocol.

18. Conclusion
• Cancer in itself is responsible for a huge burden of
morbidity and mortality in general population. During
this period of pandemic, it has become more difficult
for cancer patients to escape from COVID-19 infection
during repeated and continuous exposure to hospital
environment, so it had become the responsibility of
hospital and health care workers to take care of them
and to prevent the transmission of infection among
them. From present study we can conclude that by
following basic and universal guidelines we can protect
immunocompromised patients and health care workers
from the spread of COVID-19 infection without
compromising their radiotherapy treatment.

19. Covid 19 and philosophical thinking
• Expected to add changes to evolutionary process of
human civilization.
• Add dimensions to understanding of globalization, will
reflect on cultural values and institutional arrangement
of society.
• Realize the importance of survival, meaning of life,
reasonable life style, relation between individuals,
collective rights, relation between man and nature
,between man and other creatures and so on.
• Source:(Han Z.Frontiers of Philosophy,15(4);547-
566,2020), how have philosophers reacted to
pandemic? –ALJAZEERA,dec 2020.

20. References
1. http:/www.worldometers.info India.
2. https://www.who.int/news-room/feature-stories/detail/a-guide-to-who-s-guidance
3. Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by
Hospice Agencies.
4. AHCA COVID-19 Visitor Screening Toolkit.
5. https://www.ima-india.org/ima/pdfdata/COVID-19-Guidelines-for-Hospitals-n-Doctors
6. Whitaker M, Kron T, Sobolewski M, Dove R. COVID-19 pandemic planning: considerations for radiation
oncology medical physics. Phys Eng Sci Med. 2020; 43(2):473-480. doi:10.1007/s13246-020-00869-0
7. Ranganathan P, Sengar M, Chinnaswamy G, Agrawal G, Arumugham R, Bhatt R, Bilimagga R,
Chakrabarti J, Chandrasekharan A, Chaturvedi HK, Choudhrie R, Dandekar M, Das A, Goel V, Harris C,
Hegde SK, Hulikal N, Joseph D, Kantharia R, Khan A, Kharde R, Khattry N, Lone MM, Mahantshetty U,
Malhotra H, Menon H, Mishra D, Nair RA, Pandya SJ, Patni N, Pautu J, Pavamani S, Pradhan S,
Thammineedi SR, Selvaluxmy G, Sharan K, Sharma BK, Sharma J, Singh S, Srungavarapu GC,
Subramaniam R, Toprani R, Raman RV, Badwe RA, Pramesh CS; National Cancer Grid of India. Impact
of COVID-19 on cancer care in India: a cohort study. Lancet Oncol. 2021 Jul;22(7):970-976. doi:
10.1016/S1470-2045(21)00240-0. Epub 2021 May 27. PMID: 34051879; PMCID: PMC8159191.
8. Wei Wei, Dandan Zheng, Yu Lei, Shen Wu, Vivek Verma, Yongsheng Liu, Xueyan Wei, Jianping Bi,
Desheng Hu, Guang Han,Radiotherapy workflow and protection procedures during the Coronavirus
Disease 2019 (COVID-19) outbreak: Experience of the Hubei Cancer Hospital in Wuhan,
China,Radiotherapy and Oncology,Volume 148,2020,Pages 203-210,ISSN 0167-
8140,https://doi.org/10.1016/j.radonc.2020.03.029.
9. Pramesh, C.S., Chinnaswamy, G., Sengar, M. et al. COVID-19 and cancer care in India. Nat Cancer 2,
1257–1259 (2021). https://doi.org/10.1038/s43018-021-00290-w

21. Acknowledgement
• Dr. Manish Ahirwar (Assistant Professor)
• Ms. Suchishree Shukla, Mr. Kalyan Mondal
(RSO)
• Ms. Farzana S ( Medical Physicist)
• Team Radiotherapy, CMCH, Bhopal

22. Thank you
Halt and realize the importance of small things
usually forgotten to rat race in pursuit of big
gains